Content Validity of the Comprehensive ICF Core Set for Children with Cerebral Palsy Aged 0-6 Years: Iranian Occupational Therapists Perspective.

Objectives
Comprehensive ICF Core Set of cerebral palsy (CP) includes a set of functions of children with CP has been created recently. This study determined the content validity of this version based on Iranian Occupational Therapists' perspectives to explore whether the ICF Core Sets for CP include the areas of function of CP in Occupational Therapy practice.


Materials & Methods
This qualitative study conducted from Feb 2015 to Apr 2016 in Tehran, Iran. Experts were the academic staffs selected through convenience sampling. Content validity of comprehensive ICF-Core Set of CP with 135 ICF categories was done by them. Delphi survey was used for generating consensus on the final version. Participants were 50 clinical Occupational Therapists invited via email from across Iran. An agreement of 75% was considered as the cut-off for inclusion of each code-category.


Results
About 60% of the code-categories of comprehensive version of ICF Core Set of CP were approved by Occupational Therapists. In the final version, 82 code-categories were listed that included 21 code-categories for Body Functions, 40 for Activity/Participation, and 21 for Environmental Factors.


Conclusion
The validity of the Iranian ICF Core Set for children with CP aged 0-6 yr was supported by Iranian Occupational Therapists. It could be the basis for evaluation of this population in Occupational Therapy.


Introduction
Cerebral palsy (CP) refers to a group of movement disorders that is permanent and non-progressive damage to the developing brain that causes functional limitation in patients (1,2). This is the most common cause of physical disability in early childhood, with the prevalence of 2-3.5 cases per 1000 live births in developed and developing countries (3). The prevalence To facilitate the application of the ICF and ICF-CY, ICF Core Sets have been created. These are shortlists derived from the ICF to facilitate the application in clinical practice for specific health conditions.
There are two categories, brief ICF Core Sets that are minimal standards for reporting functioning and for collecting data in epidemiological studies, and the comprehensive ICF Core Sets that are standards for interdisciplinary and comprehensive assessments (16).
Several ICF Core Sets have been developed for various conditions. The ICF Core Sets for children and youth was developed with CP (CP) (17)(18)(19)(20)(21)(22). CP In our study, the authors needed a framework to allow for better perception of function in this population and to facilitate the evaluation process for Occupational Therapists assessing children aged 0-6 yr with CP. We selected the comprehensive ICF Core Set of individuals' aged 0-18 yr with CP.
The integration does not exist among specialists in identifying the problems and needs of this population that causes poor assessment and inconsistency among the experts (8).
Physiotherapists and Occupational Therapists have key roles in motor interventions for children with of CP is 2-2.6 in 1000 live births in Iran (4).
CP is often associated with disorders such as visual and hearing dysfunction, perceptual, cognitive, communication and behavioral disorders, epilepsy and musculoskeletal problems. These problems eventually change their quality of life and impose too much stress on caregivers. There are many problems in these children that varied and difficult to check (5,6).
Today, using the classification system is selfevident and necessary especially in medical sciences (7). One of the classification systems, the international classification of functioning and disability and health (ICF), is currently in clinical research and will be using it a lot (8). It provides a holistic framework that describes relevant functional information about individuals with a health condition. Professionals from the health, education and social sectors are encouraged to apply the ICF framework in day-to-day practice (9).
Owing to the multidimensional approach proposed by the ICF, occupational therapists are increasingly adopting the ICF framework and coding system in their practices (10). This category-based system and its pediatric version, the ICF for children and youth (ICF-CY), facilitates the observation and documentation of functioning of clients (10,11) and provides an effective monitoring and evaluation tool for the assessment of intervention results (12,13). Knowledge of ICF helped multiple disciplines to comprehensively evaluate individuals with CP (8,14). Teaching physiotherapy students to assess patients based on the ICF provided a conceptual framework that guided their questions and allowed them to organize and integrate information using various components of ICF (15). and multiple sclerosis (27). In fact, after doing this preliminary research we can organize current tools or prepare tools based on the validated ICF Core Sets (15).

Participants
Participants were two groups. One group of 12 The CVI uses a four-point Likert scale to rate each code-category based on 'simplicity', 'relevancy', or 'specificity', and 'clarity'. Every code-category was calculated in terms of these three features. CVI was computed as the number of experts giving a rating of either 3 or 4 for each indicator, divided by the number of experts; that is, the proportion in agreement about relevancy, simplicity, or clarity (35)(36)(37). The score for suitable code-categories was greater than 0.79; for questionable categories was a value between 0.70-0.79, and for unacceptable code-categories, it was less than 0.70 (35)(36)(37). This rule adhered to the panel and Delphi stages. Table 1 shows demographic and professional characteristics of the 12 expert Occupational Therapists and 50 clinical Occupational Therapists.

Content validity results
The first expert panel considered all 135 categories from the selected framework. Of these, 73 codecategories were accepted (agreement greater than 75%), 25 code-categories were omitted (agreement less than 50%), and 37 code-categories were borderline (agreement 50%-75%). Thirty- For quantitative validation, a framework was prepared with 95 code-categories for children (0-6 yr) and ten code-categories were omitted as they had CVRs of less than 0.56 (based on an appraisal of 12 experts) and CVIs of lower than 0.79. In addition, 25 code-categories were modified. In total, 84 code-categories were accepted with 21 code-categories for Body Function, 40 for Activity and Participation, and 23 for Environmental Factors (Table 2).

Excluded code-categories
There were two reasons for exclusion: age group of children and Occupational Therapists responsibilities. We used the comprehensive version of ICF Core Set of CP for children aged 0-18 yr of age, which meant that some codecategories were excluded such as d166 reading, d170 writing, d172 calculating, and d820 school education. Some were excluded because they fell beyond the scope of Occupational Therapists responsibility such as b530 weight maintenance functions and b620 urination functions and body Structure code-categories such as s320 structure of mouth, and s7700 bones.

Added code-categories
According to expert's comments, five codecategories were added including b144 memory functions, b235 vestibular functions, b265 touch functions, b7508 motor reflex functions, and d210 undertaking a single task, i.e. four code-categories related to Body Functions and one code-category (d210) related to Activity and Participation not covered by the Comprehensive ICF Core Set for CP. These ICF-CY code-categories are essential in Occupational Therapy evaluation and intervention with children aged 0-6 yr with CP.

Modified code-categories
Twenty-five code-categories were modified by the experts during the validation phases. Most of them were reworded to give a better sense of the concept or better understanding (Table 2).

Delphi rounds results
Content Validity of the Comprehensive ICF Core Set for Children with Cerebral Palsy Aged 0-6 Years: Iranian ...
In the first round, among 84 code-categories accepted by experts, 82 code-categories achieved greater than 75% agreement and two codecategories between 50% and 75% agreement.
Interestingly, view of both groups [academic (expert) and clinical Occupational Therapists] except in two codes was the same. Only e315 and e415 did not achieve agreement greater than 75% (Table 3).
In the second round, two code-categories -e315 (83%), e415 (76%)-achieved greater than 75% agreement by 30 Occupational Therapists for exclusion. Since consensus achieved after two rounds, 10 Occupational Therapists participated in a mini Delphi session for only the decision-making in the definitions of some code-categories that in previous rounds had been suggested.
The way in which the code-categories were derived over the course of the study to yield 82 code-categories (Figure 1).

Discussion
The aim of this study was to determine the

Evaluation of Environmental Factors and Body
Function are the responsibility of Occupational Therapists, who may carry out interventions in these areas (43). The aim was to identify CP functions for their evaluation based on ICF. In this study, children, parents and medical experts were asked to consider the problems of the person with CP. From 322 responses, 45% were related to chapter 4 (Mobility) and 45% related to Chapter 7 (Neuromusculoskeletal and movement-related functions) (44) that is compatible with our study.
Mobility problems are a priority for most of the professionals associated with this group of people. Of course, children with CP stated greatest difficulties in mobility, self-care, and leisure, while caregivers mentioned the physical limitations and environmental factors are their main concern (11).
Caregivers' perspective is a little farther than the other two groups view. Fortunately, Occupational Therapists have the client-centered approach, in order to achieve the best results, therefore, they consider all three groups attitudes in the evaluation and intervention.
The protocol used for this study was novel and differed to those used in prior validation studies (12,(25)(26)(27). In other validation studies, ICF categories were derived after the Delphi process with open questions about disorders (12,(25)(26)(27), while in the current study, ICF categories were introduced to the Occupational Therapists at first because those code-categories were the framework of our study and our participants were not very familiar with them. Explanations of some categories in ICF Core

Set of CP, especially concerning Environmental
Factors, were unclear and had to be explained to Occupational Therapists using both written and spoken language. The strength of the present work is the validation of CP ICF Core Set following its development by Schiariti (45).
The current study was limited in that the results may not be generalizable to the whole world occupational therapists. Before the study, we considered one month for each Delphi round, but in practice, each round lasted about two months.
Criteria considered for agreement in this study was 75% but in some studies cut-off 50% was considered (41). Considering higher percentage in this study resulted in some phases of the study took time longer than intended. Further international studies are needed so that cultural effects can be taken into account. It is suggested to validate of ICF Core Set for children 6 to 18 yr with cerebral palsy.
In conclusion, about 60% of the code-categories